Plotting against the NHS

23 March 2016

Tony Payne - Director of SPERI

A closely interconnected health policy community in Britain has grabbed control of the agenda and seeks to make further marketisation of healthcare the only possible option

Earlier in the year I was admitted to hospital for an operation and so I necessarily engaged with the NHS more intensively than at any other point in my lifetime. Don’t worry, though, dear reader: this isn’t going to be one of those illness blogs.  Rather, I realised when I had time to gather myself that, although I consider myself a political economist, I had never read anything at all on the political economy of the NHS.  I wasn’t even aware of any books on the topic that I should have read. Mea culpa.

Whilst convalescing at home after the operation (and in addition to watching the last series of The West Wing which, unaccountably, I had left in the DVD box unviewed), I decided to put this right and looked around at what was out there in the literature.  On brief inspection I found a lot of neoliberal economics, but very little that was genuinely political economy in inspiration – with one crucial and highly revealing exception.

This was a short book produced some time ago in 2011 by a small left-wing publishing house called Merlin Press and authored jointly by Colin Leys and Stewart Player. It was called, arrestingly, The Plot Against the NHS. Before turning to discussion of the book, which apart from a review in The Guardian in May 2011 by Richard Horton, the editor-in-chief of The Lancet, seems largely to have been ignored in the public debate in Britain about the future of the NHS, I want to draw attention – appropriately I hope for this blog – to the background of its main author, Colin Leys.

The fact is that Colin played a distant, and at the time unknowing, role in the creation of a tradition of study in political economy at Sheffield and thus by extension contributed to the foundation of SPERI. He was, albeit briefly, a professor in the Department of Political Theory and Institutions (as it was then called) at the University of Sheffield between 1972 and 1975 (before moving on to a long career at Queen’s University in Kingston, Ontario in Canada) and was the first political economist ever to have worked in the Department.  He was at that time and for a long period afterwards renowned for his highly original work on underdevelopment in Africa, helping to shape a key debate that took place in the 1970s comparing the different characteristics of Kenyan capitalism and Tanzanian socialism as rival models of economic and social development.  As Head of Department at Sheffield he also laid a great basis for future research in political economy by appointing to his first lectureship in 1973 a 26-year-old Andrew Gamble, now back again at Sheffield as a Professorial Fellow at SPERI.

Colin retired to Britain and has lately devoted his attention to health policy. He is now both an Honorary Professor at Goldsmiths University in London and an active member of a small, independent think-tank formed three years ago called The Centre for Health and the Public Interest which aims, in its own words, to set out ‘a vision of health and social care policy based on accountability and the public interest’.

So why did I find his book with Stewart Player so striking? After all, it’s now inevitably dated in respect of events.  But that in a way makes its case, because it can be read in 2016 as a tellingly accurate prophecy of the future of the NHS in Britain as it has unfolded over the last half-decade.  As indicated, the book argues in strong terms that nothing less than a ‘plot’ has been consciously mounted against the NHS from as early as 2000 by what can be described as nothing less than a new ‘medical industrial complex’.  Leys and Player knew full well the seriousness of what they were claiming here since they quote at the beginning of their first chapter the Oxford English Dictionary definition of a plot, namely, ‘a secret plan, esp. to achieve an unlawful end; a conspiracy’.  What, for them, rendered the health policy of successive British governments a plot, rather than the usual incremental muddle, was precisely its covert nature.  As they write, ‘neither parliament nor the public have ever been told honestly what was intended’; instead, ‘misrepresentation, obfuscation and deception have been involved at every stage’.

The book carefully describes all of these stages – from the ‘concordat’ with the Independent Healthcare Association, representing Britain’s at that time fledgling private healthcare industry, negotiated by Tony Blair’s second Secretary of State for Health, Alan Milburn, in 2000 through to the launch by Andrew Lansley of the Coalition Government’s White Paper of July 2010 and, in so doing, notes huge continuities of policy between New Labour and Conservative/Liberal Democrat governments. It also draws a clever and important distinction between ‘marketizers’ and ‘privatizers’, the former defined as politicians and policy-makers who wanted the NHS to operate more like a market, to ‘gee it up’, while remaining publicly funded and managed, the latter as people who thought that only private companies competing in a full healthcare market would generate the efficiency that was needed.  Yet, again and again, it was the ‘marketizers’, whether knowingly or unknowingly, who opened up political doors through which ‘privatizers’ then eagerly surged.

One of the reasons that makes the account of recent NHS policy offered by Leys and Player so plausible and indeed convincing is that, albeit without any theoretical fuss, they deploy one of the most familiar arguments of current public policy analysis, namely, the capture of policy by a specialist lobby with interests of its own. They demonstrate convincingly that all of the various reforms, variously proclaimed as means to reduce waiting times, offer more ‘choice’, achieve ‘world class’ standards and make the NHS more ‘patient-centred’ and ‘doctor-led’, actually involved ‘persistent, behind-the-scenes lobbying and fixing by a network of insiders – inside the Department of Health, above all, but also by a wider network, closely linked to the Department: corporate executives, management consultants, ministers’ ‘special advisers’, academics with free market sympathies and a taste for power, doctors with entrepreneurial ambitions – and the House of Commons Health Committee, packed with just enough compliant back-benchers and deliberately insulated from advice from expert critics of the market agenda’.

The question to which this argument unavoidably gives rise is what can be done to stop these changes. Leys and Player are less persuasive here.  They hold out some hope that Scotland and Wales have resisted some of the market pressures and call upon ‘the great majority of the public, who rely on the NHS, to stand up and fight for it’.  No-one can doubt that mass political pressure to restore the NHS to its former ethos would have to play a major part in underpinning what in effect needs to be a ‘plot’ for the NHS.  Such a plot would also require determined and persistent political leadership by a political party genuinely committed to a different NHS project.  But, even then, these forces would quickly run up against this new ‘medical industrial complex’ and its tight grip on the direction of British health policy.  The key issue exposed by Leys and Player is that of how to break up this complex and restore in Britain the practice of public policy being made in the public interest.

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